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<br /> Instructions on pa�e 7
<br /> Parcel number: _ For Local I racking Purposes:�
<br /> System status: ❑Compliani rloi�compliant j
<br /> (based on a!I compliance rec�uire en s)
<br /> - ,u��
<br /> �i 9��;+:�f �ii�Ci�;id�?��:.`�
<br /> Property o�Nner name(s):
<br /> Property address: _� �,f' y�lG L� � ��,, D�1�,�� ��,
<br /> Property ow,/ner's address(if different):
<br /> County: /�Cs✓,� Propert;�o�roner phon2 Permi ng authority:
<br /> Date system constructed: ��.� Reason for inspection: S,Q��£..
<br /> ��tei.�'``r ��tm, : y.��� --
<br /> Bnefs;�stem description: � /,d KJ�f r" _�_ ��
<br /> Local permit number: PJumber of bedrooms: _ _ Design flow rate:
<br /> !a 'r.Pt�sys'i�;-::: ---_
<br /> In Shoreland area7 ❑Yes i�!o In!�!ellhead Protec�ion i�re�7 ❑Yes �Jo
<br /> An U.S. Environmental Protection S��stem serving a c�iinnesota Departmen't
<br /> Hgency (EPH)Cfass V Injection Vl/ell?�Yes iJe of Heath(IYiDH) licensed facilify7 I j Yes � i�fo
<br /> Y:--� -=:�'=� `� �`-='� (gased on state reyuirements-additional local requirements may also apply.)
<br /> Based on the info�mation gathared and reportec!on atiached fonr�s,the compliance siatus of ihis s,rstem is(check one):
<br /> ❑�ertificate oi Compliance-valid until(3 years from dcie o;repor�i:
<br /> �iVotice of Noncompliance- For Noncompliani svstems:
<br /> I he reason fer noncompliance is: pg.(j _�,dJ Q �/yS Q, 5,,,,,�,��v,� o RG� ,vG
<br /> �-. i�-;c� �.:� � �as:�.��scl�r�i;__- .� �. —__. ------ -------
<br /> , _ __ .. .,, _.__ .� _ � e�.s �
<br /> ❑ Immrnentthreatto public health 8,safe�y �ailing to protectground water ❑iVot in compliance�r✓ith operatrng permit
<br /> .,d, � , __.;'di"� (Completedforir� mustbe subir�itted o the local unitofgovernmentwithin 15 days.)
<br /> 1 hereby cerfify that a//the nacessary i��formatlon has been gathered to determine the comp/iance status of fhis system. No
<br /> determir�atior�of futum system performance has been r�or can be made du�to unknown condrtions durrng system construction,
<br /> possible abuse of the system.rnadequaie maintenance, or future vvater usage.
<br /> � f
<br /> Name: �������y��y� Certification number: ____7�b
<br /> Business license name and number: � � (,v,e5_f__��'�`�_}.�� S'rK. ,� � ` o.,
<br /> Name of local unit of govemment: D.flB
<br /> Signaiure: Date: _ 0 i p g
<br /> —�
<br /> x ��� �. � .< inspector Complete: ns- ... �ecii�;z ;���ert is _� , i;�r,r�.
<br /> ':� �y � � -
<br /> ChiC: �o;+'uiia;'C� ioi';'rS�;�iz,�;1.t: �Hydraulic Performance l�Tank Integrity �Soil Separation �Operating Permit Form(if
<br /> applicable) ❑System drawing/As-built dra�roing ❑An assessmen�of any locaf requi ements that are diff re t from what is required ot�this
<br /> form ❑Soii Boring Logs ❑Abandonment form(if appropriate) ❑Other information (list):
<br /> �-;'-�I:'<;='� i'<',?i?i'�i71e�iS (derived from�blrnn. Stat.§115.55)An imminent"rhreat to public health and safety(17PHSJ must be upgraG�J;replaced c
<br /> rrs use drscontinued v✓ithm ten months of rrceipt of fhis noiic2 or within a shater perirxl if r�uired by lo�al o;drnance If rhe sysiem is iaiGng to,orotc�t around
<br /> water the system musi ne upgradec',replaccJ.or its use discontinued within ihe time requir�'by(e:al ordinance If an existing system is no'r failing as defined in
<br /> laiv.ard has at least i�:vo feet cf design soil separation,ihen ihe sysre�n need noi oe upgrzded repaireU replac2d or rfs use drscontinued notwithstandii�y any
<br /> Iccal ordinance�hat is more strrct This provision does noi apply to sysiems in shoreland ai zas. Wellhead P�oiscfron Araas,or tnosa used in conna;tion�roith rcrxJ
<br /> beveraye.and Icdging establishments as Uefined in la�,v
<br /> rvq-wwisis�-3i Co;n�tianca lnspecf-ion i=or;�n for FxistinQ SSTS
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